=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649696899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHELBY HEALTH CARE SERVICES; LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2014
-----------------------------------------------------
Last Update Date | 03/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12624 TROTWOOD CT
-----------------------------------------------------
City | BELTSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20705-6304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-523-9873
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12624 TROTWOOD CT
-----------------------------------------------------
City | BELTSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20705-6304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-523-9873
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. JONATHAN CHINEDU NJOKU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-523-9873
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | R3322
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------